Section 376.1387

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS

Chapter 376

Effective - 28 Aug 1997   

  376.1387.  Appeals of grievances determined by the director. — 1.  The director shall resolve any grievance regarding an adverse determination as to covered services appealed by an enrollee or health carrier or plan sponsor through any means not specifically prohibited by law but if the grievance is unresolved by the director then it shall be resolved by referral of such grievance to an independent review organization.  The director shall establish the qualifications for such review organizations(s) and shall seek the services of such organization(s) by competitive bid pursuant to chapter 34.  The director shall enter into contracts with such organization(s) as deemed necessary to conduct the adverse determination appeals process set forth in this section.  Any request for an adverse determination appeal shall be assigned on a rotational basis.  The organization's decision as to the resolution of the grievance shall be based upon a review of the written record before it.  The grievance and resolution of such grievance shall not be considered a contested case within the meaning of section 536.010, but the resolution of such grievance by the panel shall be considered a final agency decision within the director's discretion, binding upon the enrollee and health carrier, and subject to judicial review if:

  (1)  Action for such review is filed within thirty days of the final agency decision; and

  (2)  Judicial review is limited to the record before the director; and

  (3)  The enrollee and health carrier are deemed real parties in interest; and

  (4)  The scope of judicial review extends only to a determination of whether the action of the director is unconstitutional, unlawful, unreasonable, arbitrary, or capricious or involves an abuse of discretion or is in excess of the statutory authority or jurisdiction of the director.

  2.  Nothing in this section is intended to restrict the director's authority to investigate and resolve any complaint against a health carrier that does not constitute a grievance within the meaning of section 376.1350.

  3.  Any grievance involving coverage provided pursuant to a Medicaid program, however, shall be resolved in accordance with the rules and procedures established for the Medicaid program.

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(L. 1997 H.B. 335)